Strategies for Treating Patients With Multiply Relapsed Multiple Myeloma

At the 2023 Lymphoma, Leukemia & Myeloma Congress in New York, Joseph Mikhael, MD, MEd, FRCPC, FACP, Translational Genomics Research Institute, City of Hope Cancer Center, Phoenix, Arizona, shares expert insight into options for treating patients with multiply relapsed myeloma. 

Transcript:

Hello, my name is Dr Joseph Mikhael. I'm a professor at the Translational Genomics Research Institute in Phoenix, Arizona, which is part of the City of Hope Cancer Center. I have the privilege of presenting today at the Lymphoma, Leukemia and Myeloma Conference in lovely New York City, and I have the privilege of discussing what do we do in those challenging situations of the multiply relapsed patient.

The title of the talk is “From CELMoDs to XP01 Inhibitors.” What do we do in that timeframe when patients may not yet be eligible for CAR-T cell therapies or bispecific antibodies that we've been discussing at length? I will be discussing the importance of appropriately using XP01 inhibitors, namely selinexor. This is a drug that, unfortunately, has been given a bit of a bad rap initially because it was challenging to give and caused a lot of nausea and anorexia in our patients.

But like with every drug in myeloma that goes through an evolution, there's no drug in myeloma that we use now the way it was first introduced. And so, we've learned with selinexor when we give it once weekly at lower dose with anti-emetics, this drug is much more manageable, whether it's by itself or in combination. So, I'll provide some very practical tips and have provided some practical approaches to use this agent.

Also, we'll be discussing [cereblon E3 ligase modulators] (CELMoDs), which will quite likely be the next wave of treatments that we use, in addition to these great CAR-Ts and bispecifics that we have. Again, despite all these fancy therapies, we also want simple oral drugs for our patients, especially those patients who may be older, may be less fit. CELMoDs, a natural outflow of immunomodulatory drugs, will very likely be able to be used by us in myeloma in the near future, primarily the 2 key drugs, iberdomide and mezigdomide. These are oral drugs, much like lenalidomide and pomalidomide that could be used either by themselves or in combination with a similar toxicity profile, but clearly overcome the resistance of immunomodulatory drugs.

Lastly, we need to remember some principles of treating heavily relapsed patients. We don't want to give them alkylators if they're heading into a T-cell therapy because it can limit the activity of T-cells. We follow some key principles of possibly repeating prior therapies, of being aware of discordant disease between extramedullary disease and marrow disease, so it's important.

As I always say, myeloma is like a crime scene. Let's look at all elements of the disease in the blood, in the marrow, in the imaging as we follow these patients. And I do think we're going to see a true revolution in multiply relapsed myeloma with these new therapies coming in the near future.

Source:

Mikhael J. From CELMoDs to XP01 Inhibitors. Presented at Lymphoma, Leukemia & Myeloma Congress; October 18-21, 2023. New York, NY